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Legal Aspects of Health Care Administration

THIRTEENTH EDITION

George D. Pozgar, MBA, CHE, D.Litt. Author, Speaker, Consultant

Gp Health Care

Annapolis, Maryland

Legal Review Nina M. Santucci, MSCJ, JD

JONES & BARTLETT LEARNING

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Library of Congress Cataloging-in-Publication Data Names: Pozgar, George D., author. Title: Legal aspects of health care administration / George D. Pozgar, MBA, CHE, D.Litt. Description: Thirteenth edition. | Burlington, MA: Jones & Bartlett Learning, [2019] | Includes bibliographical references and index. Identifiers: LCCN 2018002863 | ISBN 9781284127171 (casebound) Subjects: LCSH: Health services administration—Law and legislation—United States. | Medical laws and legislation—United States. | Medical personnel— Malpractice—United States. | BISAC: BUSINESS & ECONOMICS / Information Management.

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https://lccn.loc.gov/2018002863
I dedicate this book to Denise Mirafuentes.

Your life was an inspiration.

Your love for family, friends, caregivers, and the many lives you have touched never failed.

Your unwavering faith in God and the challenges you faced have forever changed the lives of so many.

Your life is a testimony to goodness, kindness, and compassion.

Though the thoughts I wish to impart continue to swirl in my mind, words alone will never suffice.

So I leave you with this my dear friend,

Your signature phrase to “Live, Laugh, and Love” describes you well.

“The best and most beautiful things in the world cannot be seen or even touched, they best be felt with the heart.”

Helen Keller ALOHA & MAHALO

Until We All Meet Again

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Contents Epigraph Preface About the Book Acknowledgments

Chapter 1 Hospitals Through the Ages Learning Objectives Early Hindu and Egyptian Hospitals Greek and Roman Hospitals Hospitals of the Early Christian Era Islamic Hospitals Early Military Hospitals Medieval Hospitals The “Dark Age” of Hospitals Hospitals of the Renaissance Hospitals of the 18th Century Early Hospitals in the United States Late 19th Century Renaissance 20th-Century Progress Health Care and Hospitals in the 21st Century History Challenges Us to Do Better Chapter Review Review Questions Notes

Chapter 2 Government, Law, and Ethics Learning Objectives Development of Law Sources of Law Government Organization Department of Health and Human Services Government Ethics Political Malpractice Chapter Review Review Questions Notes

Chapter 3 Tort Law—Negligence Learning Objectives Objectives of Tort Law Negligence Forms of Negligence

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Degrees of Negligence Elements of Negligence Summary Case Chapter Review Review Questions Notes

Chapter 4 Intentional Torts Learning Objectives Assault and Battery False Imprisonment Defamation of Character Fraud Invasion of Privacy Infliction of Mental Distress Products Liability Chapter Review Review Questions Notes

Chapter 5 Tort Reform and Risk Reduction Learning Objectives Mediation and Arbitration Statute of Limitations Structured Awards Medical Malpractice Screening Panels Collateral Source Rule Contingency Fee Limitations Countersuits: Frivolous Claims Joint and Several Liability Malpractice Caps No-Fault System Regulation of Insurance Practices Reducing the Risks of Malpractice Collaboration in Tort Reform Chapter Review Review Questions Notes

Chapter 6 Criminal Aspects of Health Care Learning Objectives Criminal Procedure Healthcare Fraud Kickbacks Tampering with Drugs

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Internet Pharmacy and Sale of Drugs Falsification of Records Patient Abuse Criminal Negligence Homicide Manslaughter Rape and Sexual Assault Theft Chapter Review Review Questions Notes

Chapter 7 Contracts and Antitrust Learning Objectives What Is a Contract? Types of Contracts Elements of a Contract Breach of Contract Corporate Contracts Partnership Agent Independent Contractor Conditions Performance Nonperformance Defenses Remedies Employment Contracts Medical Staff Bylaws: A Contract Exclusive Contracts Restraint of Trade Hospital Staff Privileges Transfer Agreements Insurance Contract Chapter Review Review Questions Notes

Chapter 8 Civil Procedure and Trial Practice Learning Objectives Pleadings Discovery Motions Pretrial Conference Notice of Trial Memorandum of Law The Courtroom and the Judge

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The Jury Subpoenas Burden of Proof Res Ipsa Loquitur Opening Statements Examination of Witnesses Judicial Notice Rule Evidence Defenses Against Plaintiff’s Allegations Closing Statements Judge’s Charge to the Jury Jury Deliberation and Determination Awarding Damages Joint and Several Liability Appeals Execution of Judgments Chapter Review Review Questions Notes

Chapter 9 Corporate Structure and Legal Issues Learning Objectives Authority of Corporations Corporate Committee Structure Corporate Ethics Corporate Negligence Doctrine of Respondeat Superior Governing Body Responsibilities Corporate Reorganization and Mergers Chapter Review Review Questions Notes

Chapter 10 Medical Staff Organization and Malpractice

Learning Objectives Medical Staff Organization Medical Director Medical Staff Privileges Common Medical Errors Patient Assessments Diagnosis Treatment Discharge and Follow-Up Care Infections Psychiatry

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Principles of Medical Ethics Physician–Patient Relationship Chapter Review Review Questions Notes

Chapter 11 Nursing and the Law Learning Objectives Scope of Practice Nurse Licensure Nursing Careers Advanced Practice Nurses Legal Risks of Nurses Duty to Question Discharge Duty to Report Physician Negligence Chapter Review Review Questions Notes

Chapter 12 Hospital Departments and Allied Professionals

Learning Objectives Paramedics and First Responders Emergency Department Laboratory Medical Assistant Nutritional Services Pharmacy Physical Therapy Physician Assistant Radiology and Related Lawsuits Respiratory Therapist Chiropractor Dentistry Podiatrist Security Licensure and Certification of Healthcare Professionals Helpful Advice for Caregivers Chapter Review Review Questions Notes

Chapter 13 Information Management and Patient Records

Learning Objectives

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Information Management Medical Record Contents Documentation of Care Privacy Act of 1974 Health Insurance Portability and Accountability Act Patient Objects to Record Entries Ownership and Release of Medical Records Use of Patient Data Collected Retention of Records Electronic Medical Records Legal Proceedings and the Medical Record Falsification of Records Illegible Handwriting Timely Completion of Medical Records Confidential and Privileged Communications Charting: Some Helpful Advice Chapter Review Review Questions Notes

Chapter 14 Patient Consent, Rights, and Responsibilities

Learning Objectives Patient Consent Patient Rights Patient Responsibilities Chapter Review Review Questions Notes

Chapter 15 Healthcare Ethics Learning Objectives Ethics Morality Ethical Theories Principles of Healthcare Ethics Values Pillars of Moral Strength Religious Ethics and Spirituality Secular Ethics Professional Ethics Ethics Committee Reasoning and Decision Making Moral Compass Gone Astray Chapter Review Review Questions

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Notes

Chapter 16 Procreation and Ethical Dilemmas Learning Objectives Abortion Sterilization Artificial Insemination Surrogacy Chapter Review Review Questions Notes

Chapter 17 End-of-Life Issues Learning Objectives Patient Autonomy Constitutional Right to Refuse Care Legislative Response Defining Death Futility of Treatment Do-Not-Resuscitate Orders Withholding and Withdrawal of Treatment Euthanasia Physician-Assisted Suicide Advance Directives Autopsy Organ Donations and Transplantation Research, Experimentation, and Clinical Trials Human Genetics Stem Cell Research Chapter Review Review Questions Notes

Chapter 18 Legal Reporting Requirements Learning Objectives Abuse Child Abuse Senior Abuse Communicable Diseases Aids Births and Deaths Adverse Drug Reactions Physician Competency Incident Reporting Sentinel Events

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Look Closer, See Me Chapter Review Review Questions Notes

Chapter 19 Labor Relations Learning Objectives U.S. Department of Labor Unions and Healthcare Organizations National Labor Relations Act Norris–Laguardia Act Labor–Management Reporting and Disclosure Act Fair Labor Standards Act Civil Rights Act Occupational Safety and Health Act Rehabilitation Act Family and Medical Leave Act State Labor Laws Workers’ Compensation Labor Rights Management Rights Affirmative Action Plan Patient Rights During Labor Disputes Injunctions Administering Collective Bargaining Agreement Discrimination in the Workplace Chapter Review Review Questions Notes

Chapter 20 Employment at Will, Rights, and Responsibilities

Learning Objectives Employment at Will Public Policy Issues and Termination Termination Unemployment Compensation Wrongful Discharge Defending a Claim for Unfair Discharge Fairness: The Ultimate Test Effective Hiring Practices Employee Rights Employee Responsibilities The Caregiver’s Pledge Chapter Review Review Questions

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Notes

Chapter 21 Professional Liability Insurance Learning Objectives Insurance Policies Insurance Policy Provisions Conditions of Insurance Policies Liability of the Professional Intentional Torts: Coverage Denied Medical Liability Insurance Self-Insurance Trustee Coverage Mandated Medical Staff Insurance Coverage Investigation and Settlement of Claims Chapter Review Review Questions Notes

Chapter 22 Managed Care and National Health Insurance

Learning Objectives Managed Care Models of Managed Care Organizations Federally Qualified HMO State HMO Laws Case Management Firms Third-Party Administrators Utilization Review Liability for Nonparticipating Hospitals Employee Retirement Income Security Act Reducing Exposure to Liability Health Care Quality Improvement Act of 1986 Ethics in Patient Referral Act (1989) Managed Care and Legal Actions Price Fixing Market Power National Health Insurance Veterans Care Chapter Review Review Questions Notes

Author’s Afterword Glossary Index

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Epigraph I consider ethics, as well as religion, as supplements to law in the government of man.

—Thomas Jefferson, President of the United States (1743–1826)

In law a man is guilty when he violates the rights of others. In ethics he is guilty if he only thinks of doing so.

—Immanuel Kant, Philosopher (1724−1804)

Books are the carriers of civilization. Without books, history is silent, literature dumb, science crippled, thought and speculation at a

standstill. I think that there is nothing, not even crime, more opposed to poetry, to philosophy, ay, to life itself than this incessant business.

—Henry David Thoreau, Author, Poet, Philosopher (1817–1862)

It is curious—curious that physical courage should be so common in the world, and moral courage so rare.

—Mark Twain, American Author, Humorist (1835−1910)

In civilized life, law floats in a sea of ethics.

—Earl Warren, Chief Justice of the United States (1891–1974)

How far you go in life depends on your being tender with the young, compassionate with the aged, sympathetic with the striving, and

tolerant of the weak and the strong— because someday you will have been all of these.

—George Washington Carver, American Inventor (1864–1943)

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Preface He has achieved success who has lived well, laughed often and loved much; who has gained the respect of intelligent men and the love of

little children; who has filled his niche and accomplished his task; who has left the world better than he found it, whether by an improved poppy, a perfect poem, or a rescued soul; who has never lacked appreciation of earth’s beauty or failed to express it; who has always looked for the best in others and given them the best he had; whose life was an inspiration; whose memory a benediction.

—Bessie Stanley

egal Aspects of Health Care Administration, Thirteenth Edition, as with the previous 12 editions, continues to be the most comprehensive and

engaging book encompassing both the legal and ethical issues of healthcare administration. The Thirteenth Edition continues its tradition of providing a solid foundation in a wide range of current healthcare topics in an understandable format that carefully guides the reader through the complex maze of law and ethics, as well as an overview of practical ways to improve quality and safety in the delivery of patient care. As in previous editions, the Thirteenth Edition serves as a valuable tool for both undergraduate and graduate programs. Additionally, as has been well recognized by practicing healthcare professionals, Legal Aspects of Health Care Administration continues to be a valuable reference tool in their day-to-day work activities.

The author infuses life into the educational process through legal case studies that have been litigated in the courtroom or reported in the press, as well as real-world healthcare events through “reality checks” experienced by patients and healthcare professionals. The author’s approach inspires dynamic discussion and excitement in the learning process, thus creating an atmosphere of interest and participation, which is conducive to learning.

Although the court cases relating examples of malpractice are often mirror images of the failures of medicine, this Thirteenth Edition provides a comprehensive resource from which the reader will learn how the law, ethics, and medicine intertwine. The contents of this book serve as a reminder to its readers of the need to learn from the mistakes and tragedies experienced by others to avoid repeating them. The legal cases and resulting headlines should stand as a reminder of the responsibility that caregivers bear to the profession they have chosen.

With revised estimates that as many as 400,000 patients die each year as a result of medical errors, according to a September 2013 study reported in the Journal of Patient Safety, it is mandatory that caregivers be ever mindful of the

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nature of the life-and-death settings within which they work. At the time of this writing the headlines continue to repeat themselves. For example, on December 4, 2014, an Oregon hospital’s medication error led to the death of a 65-year-old patient. This error resulted in three employees being placed on administrative leave. The knowledge gained here will help prevent caregivers from becoming the next headline.

Although there will always be a “next time” for human error, the reader who grasps the contents in this book and understands its lessons will better understand how failures can turn to success and the pain of past mistakes can turn to hope. The application of the knowledge gained from this book and in the classroom learning process will serve to improve the competency of the reader and the quality of life for the patient through an educational process that will help prevent further injury in the healing process.

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About the Book Legal Aspects of Health Care Administration, Thirteenth Edition, lays a strong foundation in both health law and ethics. Chapter 1 begins with a review of hospitals through the ages, providing the reader with an overview of the historical development of hospitals as influenced by medical progress. This allows the reader to see the successes and failures of hospitals through the centuries and how history has a way of repeating itself, thus creating a need to learn from past mistakes in order to prevent repeating them. Chapter 2 continues with an introduction to government, law, and ethics.

Chapters 3 and 4 introduce the reader to negligence and intentional torts. Chapter 5 discusses tort reform and risk reduction, thus reducing the costs of health care. Chapter 6 reviews the criminal aspects of health care, and Chapter 7 reviews the basics of contract law as it pertains to healthcare professionals. The reader is then introduced to civil procedure and trial practice in Chapter 8. The reader’s journey continues with a discussion of corporate structure and related legal issues in Chapter 9. A review of medical staff organization and physician liability is covered in Chapter 10, followed by nursing and the law and common nursing practice errors in Chapter 11. Chapter 12 reviews the legal risks of various other hospital departments and healthcare professions.

Information management and patient records are reviewed in Chapter 13. Issues related to patient consent, rights, and responsibilities are reviewed in Chapter 14, followed by a discussion of ethical theories, principles, virtues, and values. Chapter 15 concentrates on healthcare ethics, theories, principles, and values. This review is followed by procreation and ethical dilemmas in Chapter 16, and end-of life issues in Chapter 17.

Legal reporting requirements are discussed in Chapter 18. Labor relations and employment-at-will, employee rights, and employee responsibilities are reviewed in Chapters 19 and 20, respectively. An overview of professional liability insurance, managed care, and national health insurance is provided in Chapters 21 and 22.

The practical application of the law and ethics in the healthcare setting is accomplished by interspersing the thoughts of great minds through Quotes, applicable News Clippings, provider and organizational experiences through Reality Checks, and patient experiences through legal rulings and summaries through Case Law. When reviewing the various cases, the reader should consider both the ethical and legal implications of a dilemma and how they intertwine with one another. It is important to recognize that the decisions in the cases described are generally governed both by applicable state and federal statutes and common law principles. When reviewing a case, the

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reader must keep in mind that the case law and statutes of one state are not binding in another state.

There is no one magical legal or ethics book that can possibly compress into its pages the plethora of issues that have bombarded the healthcare industry. This book is merely a beginning of the study of legal and ethical issues and is an adventure that all caregivers should take. Although there is always much more that could be discussed on any one topic, the reader will understand that this book provides a solid foundation for practical everyday use as well as further study in the law and ethics.

Each life is like a novel. Filled with moments of happiness, sadness, crisis, defeat, and triumph. When the last page has been written, will

you be happy or saddened by what you read?

—Author Unknown

The Thirteenth Edition presents real-world life experiences that bring the reader through a journey of learning that provides an effective transitional stage from the classroom to the reality of the everyday work environment. When considering matters of law and ethics, healthcare professionals are usually considering matters of freedom in regard to personal choices, one’s obligations to other sentient beings, or judgments about human character and the right to choose. The author’s objective is to equip the reader with the background knowledge necessary to understand that legal and ethical behavior begins with recognizing that we have alternatives and choices in our behavior. To make good decisions, each individual must first understand that those decisions will only be as good as the knowledge and understanding he or she possesses of right and wrong. This book is not an indictment of any profession or organization. There is a deluge of ethical issues in every aspect of human existence. Although cultural differences, politics, and religion influence who we are, it is all of life’s experiences that affect who we become.

IT’S YOUR GAVEL . . . “It’s Your Gavel” boxes offer the reader an opportunity to make their own decisions about actual court cases. Many chapters begin with a case that has been reviewed by the courts in state or federal jurisdictions. After reviewing each case and subsequent relevant material, readers can take on the role of the fact finder and render a decision. Then, at the end of the respective chapters, the actual court findings and reasoning for each case are given in “The Court’s Decision” box.

▸ Case Presentation Format When reviewing the various cases in this book, the reader should consider what happened, why things went wrong, what the relevant legal issues are, and how the event could have been prevented. The reader should also

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consider how, if one fact in a particular case changed, the outcome might have been different. What would that fact be? The cases presented in the text have been chosen because of the frequency of their occurrence. The general format for each boxed case review is as follows:

Title: Each case has a title that signals the type of case to be reviewed.

Case Citation: The case citation describes where a court’s opinion in a particular case can be located. It identifies the parties in the case, the text in which the case can be found, the court writing the opinion, and the year in which the case was decided. For example, the case citation of Bouvia v. Superior Court (Glenchur), 225 Cal. Rptr. 297 (Cal. Ct. App. 1986) is described as follows:

Bouvia v. Superior Court (Glenchur): Identifies the basic parties involved in the lawsuit 225 Cal. Rptr. 297: Identifies the case as being reported in volume 225 of the California Reporter on page 297 Cal. Ct. App. 1986: Identifies the case as being decided in the California Court of Appeals in 1986

Students who wish to research a specific case should visit a law school library, which provides access to various state and regional reporters.

Facts: A review of the material facts of the case is presented.

Issues: This is the disputed point or question the judge or jury must decide. The issues discussed in any given case are selected for review based on medical and legal pertinence to the healthcare professional. Although any one case in this text may have multiple issues, emphasis is placed on those issues considered to be more relevant for the reader in the context of the topic being discussed.

Holding: The court’s ruling based on the facts, issues, and applicable laws pertaining to a case is summarized.

Reason: The rationale for the court’s decision based on the facts, issues, and relevant laws surrounding a case is presented.

Author’s Note: This book is not a definitive treatise, but rather a portrait of the ever-evolving story of health care through the study of law and ethics. It is educational in nature and should not be considered a substitute for legal advice on any particular issue. Moreover, each chapter presents an overview, rather than an exhaustive treatment, of the various topics discussed.

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The author, legal reviewers, and/or the publisher cannot be responsible for any errors or omissions, including additions to, interpretations of, and/or changes in the regulations presented in this book.

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Acknowledgments The author especially acknowledges the staff at Jones & Bartlett Learning, whose guidance and assistance was so important in making this Thirteenth Edition a reality. Special thanks to Mike Brown, Director of Product Management at Jones & Bartlett Learning, who has once again been truly an amazing leader and mentor. I would like to thank Danielle Bessette, Product Specialist, who worked diligently and tirelessly with me on this Thirteenth Edition. I would also especially like to acknowledge Sophie Teague, Senior Marketing Manager, Brooke Haley, Production Assistant, and Merideth Tumasz, Rights & Media Specialist, who worked with me on the Thirteenth Edition. Thank you for allowing me to leave behind this legacy of writing.

I am grateful to the very special people in the more than 1,000 hospitals and ambulatory sites from Alaska to Puerto Rico with whom I have consulted, surveyed, and provided education over many years. Their shared experiences have served to remind me of the importance of making this book more valuable in the classroom and as a reference for practicing healthcare professionals.

To my students in healthcare law and ethics classes at the New School for Social Research, Molloy College, Long Island University–C.W. Post Campus, Saint Francis College, and Saint Joseph’s College; my intern from Brown University; my resident in hospital administration from The George Washington University; and those I have instructed through the years at various seminars, I will always be indebted for your inspiration.

Many thanks are also extended to all of the special people at the National Library of Medicine and the Library of Congress for their guidance over the years in locating research materials.

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CHAPTER 1

Hospitals Through the Ages I was created at the end of the Renaissance, watched pirates rule the oceans as Ivan the Terrible ruled Russia, and witnessed the arrest of

Galileo for believing the Earth revolved around the Sun.

—I Am History

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▸ LEARNING OBJECTIVES

The reader, upon completion of this chapter, will be able to:

Explain how societal conflicts due to politics, religion, and warfare have both impeded the growth of hospitals and contributed to their progress. Describe how advances in medicine led to the rise of the modern-day hospital and improved the quality of patient care. Describe how the knowledge gained from best practices (e.g., infection control) can lead to progress while at the same time result in patient harm if not consistently followed over time.

We can learn from history how past generations thought and acted, how they responded to the demands of their time and how they solved

their problems. We can learn by analogy, not by example, for our circumstances will always be different than theirs were. The main thing history can teach us is that human actions have consequences and that certain choices, once made, cannot be undone. They foreclose the possibility of making other choices and thus they determine future events.

—Gerda Lerner

This chapter provides the reader with notable historical events, from ancient civilizations to the present time, which continue to revolutionize the delivery of patient care. It provides a review of the advance of civilization as disclosed in the history of hospitals and medical achievements through the ages. A study of the past often reveals errors that then can be avoided, customs that persist only because of tradition, and practices that have been superseded by others that are more effective. The past may also bring to light long-abandoned practices, which may be revived to some advantage. The story of the birth and evolution of the hospital portrays the triumph of civilization over barbarism and the progress of civilization toward an ideal characterized by an interest in the welfare of the community.

This chapter reviews some of the most amazing medical discoveries and achievements in the history of medicine. It also describes some of the failures that continue to plague the healthcare industry. The importance of the study of history is undeniable. The Spanish philosopher George Santayana (1863– 1952) recognized this all too well when he said, “Those who do not remember the past are condemned to repeat it.” George Bernard Shaw (1856–1950), an Irish dramatist and socialist, recognized the tragedies of the history of civilization when he said, “If history repeats itself, and the unexpected always happens, how incapable must man be of learning from experience.” Yes, Santayana and Shaw are right: If we do not learn from the mistakes of the past, we are doomed to repeat them. Progress in health care will only prevail so long as advances in medicine are practiced by each new generation.

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Although the struggle to progress is a road filled with many pitfalls, hope still looms.

Martin Makary wrote in the Wall Street Journal that “Medical errors kill enough people to fill four jumbo jets a week . . . To do no harm going forward, we must be able to learn from the harm we have already done.” If we do not learn from historical events to those of the present days, we are bound to repeat them. This chapter takes the reader on a journey from the past to the present, from which to spring forward on a better road that returns the people’s trust in the safety net of the nation’s hospital systems. Here, we go “back into the future” to bring forth the fruits of healthier hospitals and healthier lives. Let the reader now travel that road.

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▸ EARLY HINDU AND EGYPTIAN HOSPITALS Two ancient civilizations, the Hindu (in what is now India) and the Egyptian, had crude hospitals. Hindu literature reveals that in the 6th century BC, Buddha appointed a physician for every 10 villages and built hospitals for the crippled and the poor. His son, Upatiso, built shelters for the diseased and for pregnant women. These examples probably moved Buddha’s devotees to erect similar hospitals. Despite a lack of records, historians agree that hospitals existed in Ceylon as early as 437 BC.

During his reign from 273 to 232 BC, King Asoka built 18 hospitals that hold historical significance because of their similarities to the modern hospital. Attendants gave gentle care to the sick, provided patients with fresh fruits and vegetables, prepared their medicines, gave massages, and maintained their personal cleanliness. Hindu physicians, adept at surgery, were required to take daily baths, keep their hair and nails short, wear white clothes, and promise that they would respect the confidence of their patients. Although bedside care was outstanding for those times, medicine was only beginning to find its way.

Egyptian physicians were probably the first to use drugs such as alum, peppermint, castor oil, and opium. In surgery, anesthesia consisted of hitting the patient on the head with a wooden mallet to render the patient unconscious. Surgery was largely limited to fractures, and medical treatment was usually given in the home. Therapy away from home was often available in temples, which functioned as hospitals.

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▸ GREEK AND ROMAN HOSPITALS The term hospital derives from the Latin word hospitalis, which relates to guests and their treatment. The word reflects the early use of these institutions not merely as places of healing, but also as havens for the poor and weary travelers. Hospitals first appeared in Greece as aesculapia, named after the Greek god of medicine, Aesculapius. For many centuries, hospitals developed in association with religious institutions, such as the Hindu hospitals opened in Sri Lanka in the 5th century BC and the monastery-based European hospitals of the Middle Ages (5th century to 15th century AD). The Hotel-Dieu in Paris, a monastic hospital founded in 660 AD, is still in operation today.

In early Greek and Roman civilization, when medical practices were rife with mysticism and superstitions, temples also were used as hospitals. Every sanctuary had a sacred altar before which the patient, dressed in white, was required to present gifts and offer prayers. If a patient was healed, the cure was credited to miracles and divine visitations. If the patient remained ill or died, he or she was considered to be lacking in purity and unworthy to live.

Greek temples provided refuge for the sick. One of these sanctuaries, dedicated to Aesculapius, is said to have existed as early as 1134 BC at Titanus. Ruins attest to the existence of another, more famous Greek temple built several centuries later in the Hieron, or sacred grove, at Epidaurus. Here, physicians ministered to the sick holistically in body and soul. They prescribed medications such as salt, honey, and water from a sacred spring. They gave patients hot and cold baths to promote speedy cures and encouraged long hours of sunshine and sea air, combined with pleasant vistas, as an important part of treatment. The temple hospitals housed libraries and rooms for visitors, attendants, priests, and physicians. The temple at Epidaurus even boasted what might be described as the site of the first clinical records. The columns of the temple were inscribed with the names of patients, brief histories of their cases, and comments as to whether or not they were cured.

The aesculapia spread rapidly throughout the Roman Empire, as well as through the Greek world. Although some hospitals were simply spas, others followed the therapy outlined by the leading physicians of the day. Hippocrates, for example, a physician born about 460 BC, advocated medical theories that have startling similarity to those of the present day. He employed the principles of percussion and auscultation, wrote intelligently on fractures, performed numerous surgical operations, and described such conditions as epilepsy, tuberculosis, malaria, and ulcers. He also kept detailed clinical records of many of his patients. Physicians like Hippocrates not only cared for patients in the temples, but also gave instruction to young medical students.

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▸ HOSPITALS OF THE EARLY CHRISTIAN ERA Christianity and the doctrines preached by Jesus stressing the emotions of love and pity gave impetus to the establishment of hospitals, which, with the advance of Christianity, became integral parts of the church institution. These Christian hospitals, which replaced those of Greece and Rome, were devoted entirely to care of the sick, and accommodated patients in buildings outside the church proper.

A decree of Constantine in 335 AD closed the aesculapia and stimulated the building of Christian hospitals, which, during the 4th and 5th centuries, reached the peak of their development. Many were erected by the rulers of the period or by wealthy Romans who had converted to Christianity. By the year 500, most large towns in the Roman Empire had hospitals. Nursing, inspired by religion, was gentle and considerate, but soon began to discard the medical precepts of Hippocrates, Antyllus, and other early Greek physicians because of their pagan origins. Instead, health care turned toward mysticism and theurgy (the working of a divine agency in human affairs) as sources of healing.

Hospitals rarely succeeded during the centuries leading to the Middle Ages; only a few existed outside Italian cities. Occasional almshouses in Europe sheltered some of the sick, whereas inns along the Roman roads housed others. No provision appears to have been made for care of the thousands of helpless paupers who had been slaves and were later set free when Christianity was introduced into the Roman Empire.

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▸ ISLAMIC HOSPITALS The followers of Mohammed were almost as dedicated as the Christians in caring for the sick. In Baghdad, Cairo, Damascus, Cordova, and many other cities under their control, luxurious hospital accommodations were frequently provided. Harun al-Rashid, the glamorous caliph (a title for a religious or civil ruler claiming succession from Mohammad) of Baghdad (786–809 AD), built a system of hospitals and paid the physicians himself. Medical care in these hospitals was free. Approximately four centuries later, in 1160, a Jewish traveler reported that he had found as many as 60 dispensaries and infirmaries in Baghdad alone. The Persian physician Rhazes, who lived from approximately 850 to 923 AD, was skilled in surgery. He is believed to be the first to use the intestines of sheep for suturing and to cleanse patient wounds with alcohol. He also gave the first rational accounts of smallpox and measles.

Islamic physicians like Rhazes received much of their medical knowledge from the persecuted Christian sect known as the Nestorians. Nestorius (Archbishop of Constantinople from April 428 to August 431) was driven into the desert with his followers after having been appointed patriarch of Constantinople and took up the study of medicine. The school at Edessa, in Mesopotamia, with its two large hospitals, eventually came under the control of the Nestorians, where they established a remarkable teaching institution. Eventually driven out of Mesopotamia by the orthodox bishop Cyrus, they fled to Persia, where they established the famous school at Gundishapur, which is considered to be the true starting point of Islamic medicine. Gundishapur was home to the world’s oldest known teaching hospital and also comprised a library and a university. It was located in the present-day province of Khuzestan, in southwestern Iran, not far from the Karun River.

Islamic medicine flourished up to about the 15th century. Physicians were acquainted with the possibilities of inhalation anesthesia. They instituted precautions against adulteration of drugs and developed a vast number of new drugs. Islamic countries also built asylums for the mentally ill 1,000 years before such institutions appeared in Europe. The people of Islam made a brilliant start in medicine, but never fulfilled the great promise that glowed in their early work in medical arts and hospitalization was never fulfilled. Wars, politics, superstitions, and a nonprogressive philosophy stunted the growth of a system that had influenced the development of hospitals.

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▸ EARLY MILITARY HOSPITALS Engraved on a limestone pillar dating back to the Sumerians (2920 BC) are pictures that depict, among other military procedures, the assemblage of the wounded. The Book of Deuteronomy records that Moses established outstanding rules for military hygiene. Out of the urgency of care for the wounded in battle came much of the impetus for medical progress. Hippocrates is quoted as saying that “war is the only proper school for a surgeon.” Under the Romans, surgery advanced largely because of experience gained through gladiatorial and military surgery. Throughout the centuries, warfare has been a two-edged sword, producing tragic events while providing an environment for the advancement of surgery and medicine. From an ethical point of view, the question arises: What surgical and medical advancements might have been lost due to the failure of mankind to sit at the table of peace and compromise on differences based on logic and reason?

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▸ MEDIEVAL HOSPITALS Religion continued to be the most important factor in the establishment of hospitals during the Middle Ages. A number of religious orders created hospitia, or travelers’ rests, and infirmaries adjacent to monasteries provided food and temporary shelter for weary travelers and pilgrims. One of these, the famous alpine hospice of St. Bernard, founded in 962, gave comfort to the weary and sent its renowned dogs to the rescue of lost mountain climbers.

The hospital movement grew rapidly during the Crusades, which began in 1096. Military hospital orders sprang up, and accommodations for sick and exhausted crusaders were provided along well-traveled roads. One body of crusaders organized the Hospitallers of the Order of St. John, which in 1099 established in the Holy Land a hospital capable of caring for 2,000 patients. Knights of this order took personal charge of service to patients and often denied themselves so that the sick might have food and medical care. For years, these institutions were the best examples of hospitals of that period.

Although physicians cared for physical ailments to afford relief, they rarely attempted to cure the sick. Dissection of a human body would have been sacrilege because the body was created in the image of God.

Finally, an active period of hospital growth came during the late 12th and early 13th centuries. In 1198, Pope Innocent III urged hospitals of the Holy Spirit to be subscribed for by the citizenry of many towns. He set an example by founding a model hospital in Rome, known as Santo Spirito, in Sassia. Built in 1204, it survived until 1922, when it was destroyed by fire. In Rome, nine other hospitals were founded shortly after completion of the one in Sassia; it is estimated that in Germany alone, 155 towns had hospitals of the Holy Spirit during early medieval times.

Although most hospitals constructed during the Middle Ages were associated with monasteries or founded by religious groups, a few cities, particularly in England, built municipal institutions. Like all hospitals of the period, the buildings were costly and often decorated with colorful tapestries and stained glass windows, but the interiors were frequently little more than large drafty halls with beds lining each side. Some hospitals were arranged on the ward plan, usually built in the shape of a cross. Floors were made of red brick or stone, and the only ventilation came from the cupola in the ceiling.

With the spread of leprosy during the 12th and 13th centuries, lazar houses sprang up, supplying additional hospital facilities. Made up of crude structures, lazar houses were usually built on the outskirts of towns and maintained for the segregation of lepers rather than for their treatment. Special groups of attendants, including members of the Order of St. Lazar, nursed the patients.

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The group represented an important social and hygienic movement because their actions served to check the spread of epidemics through isolation. The group is credited for virtually stamping out leprosy.

During the same period of hospital growth, three famous London institutions were established: St. Bartholomew’s in 1137, St. Thomas’s before 1207, and St. Mary of Bethlehem in 1247. St. Bartholomew’s, founded by Rahere (reportedly the court jester of Henry I), cared for the sick poor but, unlike many hospitals of that day, was well organized. St. Thomas’s Hospital was founded by a woman who was later canonized St. Mary Overie. It burned in 1207, was rebuilt 6 years later, and was constructed again on a new site in 1228. St. Mary of Bethlehem was the first English hospital to be used exclusively for the mentally ill.

The Hotel-Dieu of Paris was probably typical of the better hospitals of the Middle Ages. Built at the beginning of the 13th century, the hospital provided four principal rooms for patients in various stages of disease, as well as a room for convalescents and another for maternity patients. Illustrations by artists of the time show that two persons generally shared one bed.

Heavy curtains sometimes hung from canopies over the bed to afford privacy, but this advantage was more than offset by the fact that the draperies, which were never washed, spread infection and prevented free ventilation. The institution was self-contained, maintaining a bakery, herb garden, and farm. Often, patients who had fully recovered remained at the hospital to work on the farm or in the garden for several days in appreciation for the care they had received.

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▸ THE “DARK AGE” OF HOSPITALS Pictures and records of hospitals during the Middle Ages illustrate how many hospitals commonly crowded several patients into one bed regardless of the type or seriousness of the illness. A mildly ill patient might be placed in the same bed as an occupant suffering from a contagious disease. A notable exception to the general deterioration in medicine during this era was the effort of those monks who copied by hand and preserved the writings of Hippocrates and other ancient physicians.

The great Al-Mansur Hospital, built in Cairo in 1276, struck a contrast to the European institutions of the Middle Ages. It was equipped with separate wards for the more serious diseases and provided outpatient clinics. The handful of hospitals like Al-Mansur would lay the groundwork for hospital progress to come in later centuries.

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▸ HOSPITALS OF THE RENAISSANCE During the revival of learning around the close of the 14th century, hundreds of medical hospitals in Western Europe received the new, more inquiring surgeons that the Renaissance produced. New drugs were developed, and anatomy became a recognized study. Ancient Greek writings were printed, and dissection was performed by such masters as Leonardo da Vinci, known as the originator of cross-sectional anatomy, and Andreas Vesalius, author of De Humani Corporis Fabrica (On the Fabric of the Human Body), on human anatomy. Hospitals became more organized. Memoranda from 1569 describe the duties of the medical staff in the civil hospital of Padua, a city that was home to the most famous medical school of the 16th century. These read:

There shall be a doctor of physic upon whom rests the duty of visiting all the poor patients in the building, females as well as males; a doctor of surgery whose duty it is to apply ointments to all the poor people in the hospital who have wounds of any kind; and a barber who is competent to do, for the women as well as the men, all the other things that a good surgeon usually does.

The practice of surgery during the Renaissance became more scientific and progressive. Operations for lithotomy and hernioplasty were undertaken without the use of anesthetics, and surgery was practiced by the long-robe surgeons, a small group who were educated in the universities and permitted to perform all types of operations, and by the short-robe surgeons, the barbers who, in most communities, were allowed only to leech and shave the patient, unless permission was granted to extend the scope of treatment. Both groups were regarded as inferior to physicians.

In 1506, a band of long-robe surgeons organized the Royal College of Surgeons of Edinburgh. By 1540, both the long- and short-robe surgeons in England joined to form the Company of Barber-Surgeons of London. In 1528, Thomas Linacre, physician to Henry VIII, founded and became the first president of the Royal College of Physicians of England.

Although English physicians were organized during the 16th century, Henry VIII of England ordered that hospitals associated with the Catholic Church be given over to secular uses or destroyed. The sick were turned out into the streets. Conditions in hospitals became so intolerable that the king was petitioned to return one or two buildings for the care of patients. Henry consented and restored St. Bartholomew’s in 1544. Practically the only hope for the sick poor from outlying towns was to journey many miles to London.

The dearth of hospitals in England continued throughout the 17th century, when the medical school was developed. The French and the English quickly